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Chapter 8
Nursing Care of Women with Complications During Labor and Birth
Obstetric Procedures
Amnioinfusion
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Oligohydramnios
Umbilical cord compression
Reduction of recurrent variable decelerations
Dilution of meconium-stained amniotic fluid
Replaces the “cushion” for the umbilical cord and relieves the variable decelerations
Obstetric Procedures (cont.)
Amniotomy
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The artificial rupture of membranes
Done to stimulate or enhance contractions
Commits the woman to delivery
Stimulates prostaglandin secretion
Complications
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Prolapse of the umbilical cord
Infection
Abruptio placentae
Obstetric Procedures (cont.)
Observe for complications post-amniotomy
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Fetal heart rate outside normal range (110-160 beats/min) suggests umbilical cord
prolapse
Observe color, odor, amount, and character of amniotic fluid
Woman’s temperature 38° C (100.4° F) or higher is suggestive of infection
Green fluid may indicate that the fetus has passed a meconium stool
Nursing Tip
Observe for wet underpads and linens after the membranes rupture. Change them as
often as needed to keep the woman relatively dry and to reduce the risk for infection or
skin breakdown.
Induction or Augmentation of Labor
Induction is the initiation of labor before it begins naturally
Augmentation is the stimulation of contractions after they have begun naturally
Indications for Labor Induction
Gestational hypertension
Ruptured membranes without spontaneous onset of labor
Infection within the uterus
Medical problems in the woman that worsen during pregnancy
Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between
fetal and maternal blood types
Placental insufficiency
Fetal death
Contraindications to Labor Induction
Placenta previa
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Umbilical cord prolapse
Abnormal fetal presentation
High station of the fetus
Active herpes infection in the birth canal
Abnormal size or structure of the mother’s pelvis
Previous classic cesarean incision
Pharmacological Methods to
Stimulate Contractions
Cervical ripening
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Prostaglandin in a gel or vaginal insert is applied before labor induction to soften the
cervix
Laminaria is an alternative to cervical ripening by swelling inside the cervix
Oxytocin induction and the augmentation of labor
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Used to initiate or stimulate contractions
Most commonly used method
Benefit of Augmentation
Usually requires less total oxytocin than induction
Uterus is more sensitive to the drug when labor has already begun
Nonpharmacological Methods to Stimulate Contractions
Walking
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Stimulates contractions
Eases pressure of the fetus on the mother’s back
Adds gravity to the downward force of contraction
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Nipple stimulation of labor
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Causes the pituitary gland to secrete natural oxytocin
Complications of Oxytocin Induction and Augmentation of Labor
Most common is related to
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Overstimulation of contractions
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Fetal compromise
Uterine rupture
Water intoxication
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Inhibits excretion of urine and promotes fluid retention
Bishop’s Scoring System
Evaluates the cervical response to induction procedures
A high score (above 6) is predictive of successful labor induction because the cervix has
ripened or softened in preparation for labor
Version
A method used to change fetal presentation
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Two methods
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External
Internal
Risks and Contraindications of Version
Disproportion between mother’s pelvis and fetal size
Abnormal uterine or pelvic size or shape
Abnormal placental placement
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Previous cesarean birth with vertical uterine incision
Active herpes virus infection
Inadequate amniotic fluid
Poor placental function
Multifetal gestation
Fetus can become entangled in umbilical cord
Episiotomy and Lacerations
Episiotomy—controlled surgical enlargement of the vaginal opening during birth
Lacerations—uncontrolled tear of the tissues that results in a jagged wound
Perineal Lacerations
First degree—superficial vaginal mucosa or perineal skin
Second degree—involves vaginal mucosa, perineal skin, and deeper tissues of the
perineum
Third degree—same as second degree, plus involves anal sphincter
Fourth degree—extends through the anal sphincter into the rectal mucosa
Episiotomies
Indications for an Episiotomy
Better control over where and how much the vaginal opening is enlarged
An opening with a clean edge rather than the ragged opening of a tear
Note: Perineal massage and stretching exercises before labor may be an alternative to an
episiotomy
Forceps Extraction
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Provides traction and rotation of the fetal head when the mother’s pushing efforts are
insufficient to accomplish a safe delivery
Forceps may also help the physician extract the fetal head through the incision during a
cesarean birth
Forceps to Assist the
Birth of the Fetal Head
Vacuum Extraction Birth
Uses suction applied to the fetal head so the physician can assist the mother’s expulsive
efforts
Used only with occiput presentation
Vacuum Extraction Birth (cont.)
Risks of Forceps or Vacuum Extraction
Trauma to maternal or fetal tissues
Mother may have a laceration or hematoma in her vagina
Infant may have bruising, facial or scalp lacerations or abrasions, cephalhematoma, or
intracranial hemorrhage
Cesarean Birth
The surgical delivery of the fetus through incisions in the mother’s abdomen and uterus
Indications for Cesarean Birth
Abnormal labor
Inability of the fetus to pass through the mother’s pelvis
Maternal conditions such as GH or DM
Active maternal herpes virus
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Previous surgery on the uterus
Fetal compromise
Placenta previa or abruptio placentae
Risks of Cesarean Birth
Mother
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Anesthesia
Respiratory complications
Hemorrhage
Blood clots
Injury to urinary tract
Delayed intestinal peristalsis
Infection
Neonate
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Inadvertent preterm birth
Respiratory problems because of delayed absorption of lung fluid
Injury
Types of Incisions
Skin
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Vertical allows more room for a large fetus
Transverse (a.k.a. Pfannenstiel)
Uterine
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Low transverse: not likely to rupture during another birth; VBAC possible with this
type
Low vertical: minimal blood loss; more likely to rupture during another birth
Classic: rarely used; more blood loss; most likely to rupture during another
pregnancy
Sequence of Events in
Cesarean Birth
Cesarean Section Birth
Woman may need more emotional support
Emotional care of the partner and family is essential
Nursing Care in the Recovery Room
Vital signs to identify hemorrhage or shock
IV site and rate of solution flow
Fundus for firmness, height, and midline position
Dressing for drainage
Lochia for quantity, color, and presence of clots
Urine output from the indwelling catheter
Safety Alert
Although assessing the uterus after cesarean birth causes discomfort, it is important to do
so regularly
The woman can have a relaxed uterus that causes excessive blood loss, regardless of
how she delivered her child
Abnormal Labor
Called dysfunctional labor
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Does not progress
Dystocia
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Difficult labor
Risk Factors for Dysfunctional Labor
Advanced maternal age
Obesity
Overdistention of uterus
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Hydramnios or multifetal pregnancy
Abnormal presentation
Cephalopelvic disproportion (CPD)
Overstimulation of the uterus
Maternal fatigue, dehydration, fear
Lack of analgesic assistance
Problems with the Powers of Labor
Hypertonic
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Increased muscle tone
Usually occurs during the latent phase of labor
Characterized by contractions that are frequent, cramplike, and poorly coordinated
Painful but nonproductive
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Uterus is tense, even between contractions, leads to reduced blood flow to the
placenta
Hypotonic
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Decreased muscle tone
Labor begins normally, but diminishes during active phase
More likely to occur if uterus is overdistended
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Ineffective Maternal Pushing
Woman may not understand which technique to use or fears tearing her perineal tissues
Epidural or subarachnoid blocks may depress or eliminate the natural urge to push
An exhausted woman may be unable to gather enough energy to push
Problems with the Fetus
Fetal Size
Macrosomia—large fetus; weighs more than 4000 g (8.8 pounds)
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May not fit through birth canal
Can contribute to hypotonic labor dysfunction
Shoulder Dystocia
Usually occurs when fetus is too large
Is an emergency
Fetal chest cannot expand and the fetus needs to be able to breathe
After delivery, mother and infant need to be assessed for injuries
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Stretches the muscle fibers and reduces their ability to contract effectively
Mother may have torn perineal tissue
More at risk for uterine atony and postpartum hemorrhage
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Uterus does not contract well after birth
Infant may have fractured clavicle
Abnormal Fetal
Presentation or Position
Prevents the smallest diameter of the fetal head to pass through the smallest diameter of
the pelvis
Abnormal Presentations
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Does not pass easily
Interferes with most efficient mechanisms of labor
Can cause cord compression
May require external version
Abnormal Positions
Common cause is a fetus that remains in a persistent occiput posterior position
Labor may last longer
Woman may experience intense and poorly relieved back and leg pain
May require forceps-assisted delivery
Breech Birth
Nursing Care for Abnormal Fetal Presentation or Positions
Encourage woman to assume positions that favor fetal rotation and descent and reduce
back pain
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Sitting, kneeling, or standing while leaning forward
Rocking the pelvis back and forth while on hands and knees (encourages rotation)
Side-lying
Squatting (in second stage of labor)
Lunging by placing one foot in a chair with the foot and knee pointed to that side
Multifetal Pregnancy
May cause dysfunctional labor
Uterine overdistention contributes to poor contraction quality
Abnormal presentation or position of one or more fetuses interferes with labor
mechanisms
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Often one fetus is delivered as cephalic and the second as breech, unless a version is
done
Problems with the Pelvis
and Soft Tissues
Bony pelvis
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Gynecoid pelvis most favorable for vaginal birth
Soft tissue obstructions
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Most common is a full bladder
The Psyche
Most common factors that can prolong labor
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Lack of analgesic control of excessive pain
Absence of a support person or coach
Immobility and restriction to bed
Lack of ability to carry out cultural traditions
Increased Anxiety
Causes hormones to be released
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Epinephrine
Cortisol
Adrenocorticotropic
Reduces contractility of the smooth muscle
Effects of Hormones Released
The uterus uses more glucose for energy
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Diverts blood from the uterus
Increases tension of pelvic muscles; can impede fetal descent
Increases perception of pain
Abnormal Duration of Labor
Friedman’s curve
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Often used to graph the progress of cervical dilation and fetal descent
Used as a guide to assess and manage the normal progress of labor
Prolonged labor can cause
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Maternal or newborn infection
Maternal exhaustion
Postpartum hemorrhage
Greater anxiety and fear
Precipitate Birth
A birth that is completed in less than 3 hours
Labor begins abruptly and intensifies quickly
Contractions may be frequent and intense
May have uterine rupture, cervical lacerations, or hematoma
Fetal oxygenation may be compromised
Birth injury may occur from rapid passage through the birth canal
Injuries can include
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Intracranial hemorrhage
Nerve damage
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Premature Rupture
of Membranes (PROM)
Spontaneous rupture of membranes at term, more than 1 hour before labor contractions
begin
Vaginal or cervical infection may cause PROM
Diagnosis confirmed by
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Nitrazine paper test
Looking for a “ferning” pattern from vaginal fluid placed on a slide and viewed under
the microscope
Patient Teaching for a Woman with Infection or in Preterm Labor
Report a temperature that is above 38° C (100.4° F)
Avoid sexual intercourse or insertion of anything into vagina
Avoid orgasms
Avoid breast stimulation
Maintain any activity restrictions prescribed
Note any uterine contractions, reduced fetal activity, and other signs of infection
Record fetal kick counts daily and report fewer than 10 kicks in a 12-hour period
Preterm Labor
Occurs after 20 weeks and before 37 weeks gestation
Main risks are problems of immaturity in the newborn
Signs of Impending Preterm Labor
A shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor
A fibronectin test
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The presence of fibronectin in vaginal secretions between 22 and 24 weeks
gestation is predictive of preterm labor
Fibronectin is a protein produced by the fetal membranes that can leak into vaginal
secretions if uterine activity, infection, or cervical effacement occurs
Maternal Symptoms of Preterm Labor
Contractions that may be either uncomfortable or painless
Feeling that the fetus is “balling up” frequently
Menstrual-like cramps
Constant low backache
Pelvic pressure or a feeling that the fetus is pushing down
A change in vaginal discharge
Abdominal cramps with or without diarrhea
Pain or discomfort in the vulva or thighs
“Just feeling bad” or “coming down with something”
Some Risk Factors for Preterm Labor
Exposure to DES
Underweight
Chronic illness
Dehydration
Preeclampsia
Previous preterm labor or birth
Previous pregnancy losses
Substance abuse
Chronic stress
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Infection
Anemia
Preterm PROM
Inadequate prenatal care
Poor nutrition
Low education level
Poverty
Smoking
Multifetal presentation
Tocolytic Therapy
Goal is to stop uterine contractions
Keep fetus in utero until lungs are mature enough to adapt to extrauterine life
Magnesium sulfate IV drug of choice
Beta-adrenergic drugs given orally
Calcium channel blockers given orally
Contraindications
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Preeclampsia
Placenta previa
Abruptio placentae
Chorioamnionitis
Fetal demise
Stopping Preterm Labor
Initial measures to stop preterm labor
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Hydration
Steroids increase fetal lung maturity
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Betamethasone
Thyroid-releasing hormone also enhances lung maturity in fetuses younger than 28
weeks
Prolonged Pregnancy
Lasts longer than 42 weeks
Risks
Placenta ages
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Activity restriction
If it appears preterm birth is inevitable
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Identifying and treating infection
Delivers oxygen and nutrients to the fetus less efficiently
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Fetus may lose weight
Fetal skin may peel
Fetus continues to grow
Meconium may be expelled
Low blood glucose levels in the fetus
Tests Used to Confirm the Diagnosis of Prolonged Pregnancy
Any pregnancy that lasts longer than 40 weeks may require
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Nonstress tests (NST)
Amniotic fluid index (AFI)
Biophysical profiles (BPP)
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Kick counts
Emergencies During Childbirth
Prolapsed umbilical cord
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Complete
Palpated
Occult
Uterine rupture
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Complete
Incomplete
Dehiscence
Prolapsed Umbilical Cord
Nursing Care of a Woman with Umbilical Cord Prolapse
Uterine Inversion
Uterus turns inside out after delivery of the infant
Most likely to occur
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If the uterus is not firmly contracted
During vigorous fundal massage
Amniotic Fluid Embolism
Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes
meconium, enter the woman’s circulation and typically obstructs small blood vessels in her
lungs
Characterized by abrupt onset of hypotension, respiratory distress, and coagulation
abnormalities
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Question for Review
What nonpharmacological techniques can be used to stimulate labor?